PathWays Case Study: December 15

As a new lab director of a small hospital laboratory, you have reservations about the document control process currently in place. Your proposal to implement changes to the current process was met with resistance and uncertainty, despite the fact that the laboratory was due for its CAP inspection. Shortly after, the hospital underwent a CAP inspection and was cited for a Phase II deficiency for GEN.20375.


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Carrie Bowler

Carrie Bowler, MLS(ASCP)
Education Program Coordinator, DLMP Education
Mayo Clinic
Instructor in Laboratory Medicine and Pathology,
Mayo Clinic College of Medicine



Brad Karon, M.D., Ph.D.

Brad Karon, M.D., Ph.D.
Consultant, Division of Clinical Core Laboratory Services
Mayo Clinic
Associate Professor of Laboratory Medicine and Pathology,
Mayo Clinic College of Medicine


April Josselyn

April Josselyn is a Marketing Associate at Mayo Medical Laboratories. She is the editor of Mayo Clinic PathWays and supports corporate communications strategies and internal communications. She has worked at Mayo Clinic since 2012. Outside of work, April enjoys the outdoors and being "hockey mom" for her two sports-crazed boys.


good case

In this scenario; the lab director faced an almost impossible task with no good solution because even creating the sense of urgency may not have changed the outcome. Hopefully, they documented everything in terms of trying to make the change so that if a deficiency occurred, they would be ready to fix it.
Sometimes, sadly, its the deficiency that creates the urgency and is necessary to spur the change.
However, if the director had a noted an issue impinging on patient care that wasn’t getting addressed by administration because they didn’t see it or didn’t want to address it, he would have been in his right to “pull the trigger” and call the hotline. Nobody wants the press that Maryland General received.

Put current technologies into action at the earliest opportunity. Reach out to clinics and inform them of the trials, so as to coordinate data collection. Success in this area will attract investment, and funding grants.

Yes, the need for urgency is certainly good but I do not think that it would have helped in this case. And there may be some underlaying issues that needed time to be addressed. Which in this case they did not have, considering the little time they have before the CAP inspection.

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